Nursing Assessment
Nursing assessment
• thinking about what information to collect
• collecting information
• thinking about the significance of that information
• drawing conclusions about how the patient is responding to
his or health or illness condition
Nursing assessment:
2 steps
1.
2.
Collecting and verifying data from the patient and family
members
•
Patient: the primary source of information
•
Family, medical records, other health professionals:
secondary sources of information
Analyzing the data to determine the plan of care for the
patient
Databases
• The purpose of nursing assessment is to develop a database
about the client’s health status
• Patient’s perceived needs and health problems
• Patient’s responses to these problems
• The database also provides other information about the
patient’s:
Related experiences
Health practices
Goals
Values
Expectations about the health care system
Assessment-six steps
1.
collecting data
2.
identifying cues and making inferences
3.
validating data
4.
organizing (clustering data)
5.
identifying patterns/testing first impressions
6.
reporting and recording data
Database vs. focus assessment
• Database assessment
• Standardized start-of-care assessment tool for each
patient – includes information about all body systems
and issues important to the patient’s health
• Comprehensive and accurate data base assessment
system that is standardized and reproducible
• Focus assessment
• Data gathered to determine the status of a specific
condition
• For example: a diabetic’s blood sugar history or a
patient’s eating habits
Objective data
• Observations or measurements that are made by the nurse
• Examples:
• Size of a wound or lesion
• Blood pressure, temperature, pulse rate
• Amount of urine output
• If it can be measured with equipment or sensors, it is
objective data
Subjective data
• Data that can only be provided by the patient
• Feelings, impressions, sensations, beliefs, attitudes
• Anxiety, pain, mental stress, relief, joy, grief
• Only patients can provide subjective data about their
feelings, although some problems may result in
physiological changes that can be measured objectively
• For example: severe pain will often cause increased
heart rate and blood pressure
Patient interview
• Good for getting information about:
• “What brings you here” (chief complaint)
• Health history
• Introduce yourself
• Be professional but be pleasant
• Be sure to state your position (RN, student nurse, etc.)
• Patients usually love student nurses- don’t be afraid to let
them know that you are a student!
Patient interview
• Sometimes patients are not too keen on admitting
why they are there• Patients sometimes have embarrassing reasons
for seeking health care
• Don’t be judgmental, don’t show emotion- just
be professional and supportive to the patient
• You can let your emotions out later, away from
the patient!
Patient interview
• It is usually best to do the health history first,
before doing a physical examination
• The patient will get to know you a bit and start
to become comfortable with you before
invasive/intrusive examination procedures
begin
• Try to do the patient interview where you won’t be
interrupted or overheard
Patient interview
• Try to be yourself, and relax so that you can put
the patient at ease as much as possible
• If you appear stiff and tense, the patient will feel
the same way
• Go through your questions carefully, and pay
attention to the patient’s answers
• Don’t become so engrossed in writing down
answers that you miss the patient’s body language
Putting patients at ease
• When I meet new patients who are anxious, I try
to find some area that we have in commoncrossword puzzles, TV, movies, whatever- to help
put them at ease
• Once patients are comfortable talking with you
about a safe topic, then they will usually be more
comfortable talking about topics of a more
sensitive nature
A note about working with patients
• I think that the best part of nursing is the nurse-patient
relationship
• When the nurse realizes that the patient is a person with
real thoughts and feelings, and the patient realizes the same
about the nurse, a special connection forms
• That connection is what makes nursing really great for
me… An interaction begins that goes beyond a job- it
becomes a helping relationship between two people that
leaves the nurse and the patient better because of the
encounter
Patients
• When working with patients and their families, you often
will get front-row seats to some of the best and worst times
of their lives
• It is important to be supportive and empathetic but not
become dragged down by their grief or loss
• Patients and families may get angry, upset or frantic- Be
supportive and professional.
• Sometimes it helps to just let the patient or family vent
their feelings. Do what you can and don’t take it
personally.
Validating (verifying) data
• verifying that your data is factual and complete
• need to avoid:
•
•
•
•
making assumptions
missing key information
misunderstanding situation
jumping to conclusion or focusing in the wrong
direction
• making errors in problem identification
Once you have your data verified…
You need to organize it!
• Some facilities will have forms to fill out that have
everything organized.
• Sometimes you will have to do it yourself.
• There are lots of ways to organize your data
• Can organize head to toe (useful for physical
assessments)
• Or into groups like Gordon’s Functional Health Patterns
Gordon’s Functional Health Patterns
-may be used to organize assessment data
• Health perception &
management
• Activity & exercise
• Nutrition & metabolism
• Elimination
• Sleep and Rest
• Cognition & perception
• Self-perception & selfconcept
• Roles & relationships
• Coping & stress
management
• Sexuality & reproduction
• Values & beliefs
Analyzing data
• Once you have your data organized, you will want to look
through it to identify patterns
• For instance- you might notice that the patient…
• Smokes 2 packs per day
• Has a congested cough and wheezes
• Gets short of breath easily
• This patient obviously has some respiratory issues going
on, so you can:
• Consider respiratory-related nursing diagnoses
• Do some additional physical assessments- check the
patient’s oxygen saturation, look for nail clubbing, etc.
• This is where critical thinking comes in!!!
Documenting
• Be sure to document all of your findings from the
interview/health history and physical examination.
• Make notes while you are doing the interview and
assessment, and save the rest for afterward
• Patients don’t like to sit and watch you write long notes
about them
• When you are at clinical - any abnormal, unusual, or
unexpected findings must be reported to your instructor in
addition to being documented in the patient’s chart!